Nursing intervention with rationale:
1. Implement appropriate isolation techniques, as indicated.
Rationale: Dependent on type and extent of wounds, and the choice of wound treatment (e.g., open versus closed); isolation may range from simple wound and skin to complete or reverse to reduce risk of cross-contamination and exposure to multiple bacterial flora.

2. Emphasize and model good hand-washing technique for all individuals coming in contact with client.
Rationale: Prevents cross-contamination and reduces risk of acquired infection.

4. Monitor and limit visitors, if necessary. Explain isolation procedure to visitors, if used. Supervise visitor adherence to protocol as indicated.
Rationale: Prevents cross-contamination from visitors. Concern for risk of infection should be balanced against client’s need for family support and socialization.

5. Shave/clip all hair from around burned areas to include a 1-inch border (excluding eyebrows). Shave facial hair (men) and shampoo head daily.
Rationale: Hair is a good medium for bacterial growth; however, eyebrows act as a protective barrier for the eyes. Regular shampooing decreases bacterial fallout into burned areas.

7. Provide special care for eyes, for example, use eye covers and tear formulas as appropriate.
Rationale: Eyes may be swollen shut and/or become infected by drainage from surrounding burns. If lids are burned, eye covers may be needed to prevent corneal damage.

8. Prevent skin-to-skin surface contact—wrap each burned finger or toe separately; do not allow burned ear to touch scalp.
Rationale: Prevents adherence to the surface that it may be touching and encourages proper healing. Note: Ear cartilage has limited circulation and is prone to pressure necrosis.

9. Examine wounds daily; note and document changes in appearance, odor, or quantity of drainage.
Rationale: Identifies presence of granulation tissue indicating healing and provides for early detection of burn-wound infection. Infection in a partial-thickness burn may cause conversion of burn to full-thickness injury. Note: A strong, sweet, musty smell at a graft site is indicative of Pseudomonas.